THE DOUBLE KNEE SWING - A HOW-TO GUIDE AND TESTING REGIONAL INTERDEPENDENCE
10th January 2018
A decade of development
First described in the literature in 2008 (Mottram & Comerford) The Performance Matrix (TPM) movement evaluation system has evolved: a process ensuring it remains a state of the art, clinical tool.
Now delivered as an online battery of tests, risk analysis and reporting, the system’s success lies not only with its technology but also with the specificity in which it finds and helps addresses movement related deficits in performance or pain/recurrence. Additionally, each test and the testing battery as a whole is sensitive the concept of ‘regional interdependence’ (Sueki et al., 2013). Regional interdependence considers how, ‘seemingly unrelated impairments in remote anatomical regions of the body may contribute to, and be associated with, a client’s primary issue. TPM’s multi-joint testing protocol therefore supplies a clinical tool to support clinicians in multi-joint clinical reasoning process.
Individual Movement Evaluation Matters
In addition to multi-joint testing, contemporary literature is highlighting the value of the consideration of movement patterns (Hug & Tucker, 2017; Ludewig et al., 2017) and co-ordination (Fuchs & Kelso, 2018) in respect to managing individuals as individuals (see Roger Kerry’s n=1 concept) and supporting their desire to be pain free and performing at their best. The TPM approach is also focussed on the assessment of movement and the use of movement as an intervention to ensure co-ordination and movement patterns resemble a more optimal state for any individual, regardless of their past or future goals. Here we consider one test (The Double Knee Swing, McNeill, 2014), from the highly popular and most clinically applied ‘The Foundation Matrix’ (Mischiati et al., 2015), to illustrate the high resolution supplied by the testing system and analysis software.
First, the login…
The TPM Pro clinic will access their battery of tests by logging in to the system, choosing The Foundation Matrix and then showing their client the video of the first test.
Double Knee Swing (DKS)
The DKS is a non-fatiguing (low threshold) test, so the load is body weight only. It is imperative the test movement gets to the benchmark position as this test identifies not ‘if’ but ‘how’ clients get through the demands of function. Any observed and questioned compensation may not be able to be prevented which would then be identified as a failure to pass this aspect of the test - thus defining the failure as an UCM.
The start position of the test moves from a parallel standing position to a small knee bend (a). The test movement involves the knees swinging in tandem from side to side, rotating the femur in the acetabulum. The test identifies movement should be occurring at the feet, hip and knee joints without compensation elsewhere in the kinetic chain. The benchmark dictates that the knees reach 20° to each side (b).
Observing and questioning movement multi-joint movement
The tester is required to answer questions about the client’s movement control.
1. (Hip Flexion)
A movement issue might be highlighted where the hip extensors do not recruit adequately during the test, inferred by the client moving the trunk forward, as they increase flexion at the hip. This might not be a UCM unless the client has had this movement pattern pointed out to them and been given the chance to correct this potential fault (introducing a cognitive element to the testing process). If the client can prevent this strategy the client passes this part of the test. On occasions, the client may control the hip flexion tendency but swap it for another substitution pattern, so the tester then might need to make sure the client controls both potential movement faults. An uncontrolled movement needs to be proved to be uncontrolled before it can be recorded as such.
2. (Lumbo-pelvic rotation)
Another key question related to this test asks if the client can prevent rotation at the pelvis during the knee swing. For an individual to exhibit good ‘Movement Health’ (McNeill & Blandford, 2015) they are required to display control above (or below) the moving section. What might be visible to the tester is the fact that the pelvis just follows the direction that the knees swing to. The lumbo-pelvic rotation may start immediately the knees start to swing or rotation control might be exhibited during the early phase of the movement but before the knees get to the benchmark 20°, the rotation of the lumbopelvic becomes obvious.
This is why reaching the benchmarks of the test are so important. If the client shows this lumbo-pelvic rotation which might only be one direction and not the other, and cannot control it consciously once it has been brought to their attention it is marked as UCM. What might cause this uncontrolled movement? The fundamental reason is that the rotation controllers of the lumbo-pelvic region, primarily the obliques and the gluteals particularly those gluteals with an oblique fibre direction such as the gluteus medius posterior, are not engaged enough to stop the lumbo-pelvic rotation.
In addition to hip flexion and low back pelvis rotation, and because individuals can use very individual movement strategies to accommodate for limitations at one or numerous regions, more questions are asked. Sidebend of the trunk is an insidious but very common movement compensation. If the pelvis or shoulders do not stay level, sidebend is present and should be scored. Lateral rotation of the tibia is another subtle but often present accommodation for a number of different movement system related issues. Finally, the test wants the client to roll through their feet as the knees swing, however there is a question regarding inversion. Can the client prevent the ball of the foot from lifting and produce supination as opposed to inversion?
…but just one test
All in all, the five questions, related to the left and the right of the body reveals a large amount of information on this client’s particular movement control abilities, labelling issues with the site, the direction and the threshold (low in the case of this test) in which they appear. Nine more tests follow, allowing for a true understanding of the term The Performance Matrix (TPM) and a comprehensive understanding of the current state of any client’s movement. Additionally, in line with the concept of regional interdependence, movement impairments that may stay under the radar of single joint testing but may be directly associated with a client’s particular issues can be highlighted and subsequently addressed. TPM therefore supplies a triple A service: assess, analyse, address.
Fuchs, A., & Kelso, J. S. (2018). Coordination Dynamics and Synergetics: From Finger Movements to Brain Patterns and Ballet Dancing. In Complexity and Synergetics (pp. 301-316). Springer, Cham.
Hug, F., & Tucker, K. (2017). Muscle Coordination and the Development of Musculoskeletal Disorders. Exercise and sport sciences reviews, 45(4), 201-208.
Ludewig, P. M., Kamonseki, D. H., Staker, J. L., Lawrence, R. L., Camargo, P. R., & Braman, J. P. (2017). Changing Our Diagnostic Paradigm: Movement System Diagnostic Classification. International journal of sports physical therapy, 12(6), 884.
McNeill, W. (2014). The double knee swing test–a practical example of the performance matrix movement screen. Journal of bodywork and movement therapies, 18(3), 477-481.
Mischiati, C. R., Comerford, M., Gosford, E., Swart, J., Ewings, S., Botha, N., ... & Mottram, S. L. (2015). Intra and inter-rater reliability of screening for movement impairments: movement control tests from the foundation matrix. Journal of sports science & medicine, 14(2), 427.
Mottram, S., & Comerford, M. (2008). A new perspective on risk assessment. Physical Therapy in Sport, 9(1), 40-51.
Sueki, D. G., Cleland, J. A., & Wainner, R. S. (2013). A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of manual & manipulative therapy, 21(2), 90-102.
For details on joining the TPM Pro global network contact us firstname.lastname@example.org and one of our consultants would be happy to give you a demo and discuss how the system can benefit you and your clients